George Bush’s Stent Surgery Revives Debate on Heart Care

Boston Scientific Corp.'s Taxus stent, a tiny mesh tube used to keep arteries from reclogging following angioplasties, is pictured over an angioplasty balloon in this undated company photo. Source: Boston Scientific Corp. via Bloomberg

Aug. 7 (Bloomberg) -- Former President George W. Bush’s
decision to allow doctors to use a stent to clear a blocked
heart artery, performed absent symptoms, is reviving a national
debate on the best way to treat early cardiac concerns.

The discussions have been ongoing since 2007, when the
trial known as Courage first found that less costly drug therapy
averted heart attacks, hospitalizations and deaths just as well
as stents in patients with chest pain. The results were
confirmed two years later in a second large trial.

The debate has centered on both the cost of stenting, which
can run as high as $50,000 at some hospitals, and its side
effects, which can include excess bleeding, blood clots and,
rarely, death. Opponents say the overuse of procedures like
stenting for unproven benefit has helped keep U.S. medical care
on pace to surpass $3.1 trillion next year, according to the
U.S. Centers for Medicare and Medicaid Services.

“This is really American medicine at its worst,” said
Steven Nissen, head of cardiology at the Cleveland Clinic in
Ohio, in a telephone interview. “It’s one of the reasons we
spend so much on health care and we don’t get a lot for it. In
this circumstance, the stent doesn’t prolong life, it doesn’t
prevent heart attacks and it’s hard to make a patient who has no
symptoms feel better.”

Each year more than half-a-million Americans get stents,
tiny metal and mesh tubes made by Abbott Laboratories, Boston
Scientific Corp. and Medtronic Inc. inserted to hold open
clogged arteries after angioplasty.

Beneficial Use

Stents are lifesaving when patients are in the midst of a
heart attack, said Chet Rihal, an interventional cardiologist at
the Mayo Clinic in Rochester, Minnesota, who has studied use of
the devices. They allow immediate and sustained blood flow that
help a patient recover, he said.

For those who aren’t suffering a heart attack, the benefits
are less clear, according to Rihal. While stents may be used in
patients with clear chest pain, there’s no evidence that they
prevent future heart attacks, he said.

Two large-scale clinical trials completed within the last
seven years have shown that drug therapy works just as well as
stents in preventing cardiac complications. The three major U.S.
heart associations changed their guidelines in 2011 in an effort
to reduce excess treatment. A review of eight studies published
last year in JAMA Internal Medicine also found no differences.

In the Courage trial, all 2,287 patients were given
medicine to lower their cholesterol, cut their blood pressure
and prevent clots. Half also received stents to treat blockages
that cut off at least 70 percent of at least one artery. After
five years, there was no difference in deaths, heart attacks, or
hospitalizations for chest pain between the two groups.

Results Confirmed

Two years later, the results were confirmed in a second
trial involving more than 2,300 patients with diabetes and heart
disease. In that study, called Bari 2D, patients treated with
stents had the same rates of death, heart attack and stroke
after five years as those who were given medicines.

In Bush’s case, he underwent the procedure without any
symptoms after a stress test during his annual physical turned
up signs of an electrical abnormality on an EKG, according to
Freddy Ford, the former president’s spokesman. A subsequent CT
angiogram found a blockage that doctors and Bush determined
needed to be treated, he said.

Paul Chan, an associate professor at the Mid-America Heart
Institute in Kansas City, Missouri, questioned why Bush would
have undergone a stress test at all if he didn’t have symptoms.
While it’s fairly common practice for doctors to put older
patients through such tests even without chest pain, Chan said,
there’s no evidence showing it’s beneficial.

‘Trajectory Change’

“The reality is that we don’t know if we can change the
trajectory of disease in people who don’t have symptoms, are
doing fine and are physically active,” he said in a telephone
interview. “There’s no evidence treatment will help them live
longer, feel better, or have fewer heart attacks.”

While it’s not common to go directly from a physical exam
into a CT angiogram, it does occur, said John Harold, president
of the American College of Cardiology and an attending physician
at Cedars-Sinai Heart Institute in Los Angeles.

While most doctors now use drug therapy before considering
use of a stent in such cases, the decision on Bush may have come
as the result of unusual circumstance that haven’t been made
public, said Harold, who wasn’t involved in Bush’s cases.

“It’s not always a simple calculus,” Harold said in a
telephone interview. “While we use medical therapy first, the
need to pursue other interventions depends on high-risk markers.
It depends on what the team discovered and whether it was
appropriate to intervene sooner than later.”